Diagnostic ConsiderationsAmbulatory blood pressure monitoring

In adults aged 50 years and older, the 2010 Institute for Clinical Systems Improvement (ICSI) guideline on the diagnosis and treatment of hypertension indicates that systolic blood pressure (SBP) should be the major factor to detect, evaluate, and treat hypertension.
[4]

Ambulatory blood pressure monitoring (ABPM) is used to monitor daily and nocturnal blood pressure, providing information such as the percentage of elevated BP readings, overall BP load, and extent of BP fall during sleep.
[2] In general, these readings are lower than those in a physician office setting and have a better correlation with target-organ injury. There is usually a 10-20% BP drop during the night. People who do not demonstrate such a decrease in BP are at increased risk for cardiovascular events. Patients with 24-hour BP greater than 135/85 mm Hg have been shown to have almost double the likelihood of having a cardiovascular event.
[2]

Indications for ABPM include labile BP; a discrepancy between blood pressure measurements in and outside the physician’s office; and poor BP control. Ambulatory monitoring also identifies patients who have the distinct syndrome called white-coat hypertension,
[49] in which a patient’s blood pressures reading at home and in the physician’s office vary widely.
[59]

O'Riordan M. New European hypertension guidelines released: goal is less than 140 mm Hg for all. Heartwire from Medscape [serial online]. Available at http://www.medscape.com/viewarticle/806367. June 15, 2013; Accessed: June 24, 2013.

American College of Obstetricians and Gynecologists, Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013 Nov. 122 (5):1122-31. [Medline]. [Full Text].

[Guideline] Rosendorff C, Lackland DT, Allison M, Aronow WS, et al. American Heart Association, American College of Cardiology, et al. Treatment of hypertension in patients with coronary artery disease: a scientific statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension. Circulation. 2015 May 12. 131 (19):e435-70. [Medline]. [Full Text].

[Guideline] Go AS, Bauman M, King SM, et al. An effective approach to high blood pressure control: a science advisory from the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention. Hypertension. 2013 Nov 15. [Medline]. [Full Text].

[Guideline] Weber MA, Schiffrin EL, White WB, et al. Clinical practice guidelines for the management of hypertension in the community a statement by the American Society of Hypertension and the International Society of Hypertension. J Hypertens. 2014 Jan. 32 (1):3-15. [Medline]. [Full Text].

[Guideline] National High Blood Pressure Education Program Working Group. Report of the National High Blood Pressure Education Program Working Group on high blood pressure in pregnancy. Am J Obstet Gynecol. 2000 Jul. 183 (1):S1-S22. [Medline].

[Guideline] American College of Obstetricians and Gynecologists, Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013 Nov. 122 (5):1122-31. [Medline]. [Full Text].

Aronow WS, Fleg JL, Pepine CJ, Artinian NT, Bakris G, Brown AS, et al. ACCF/AHA 2011 expert consensus document on hypertension in the elderly: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus documents developed in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension. J Am Coll Cardiol. 2011 May 17. 57(20):2037-114. [Medline].

Anteroposterior x-ray from a 28-year old woman who presented with congestive heart failure secondary to her chronic hypertension, or high blood pressure. The enlarged cardiac silhouette on this image is due to congestive heart failure due to the effects of chronic high blood pressure on the left ventricle. The heart then becomes enlarged, and fluid accumulates in the lungs, known as pulmonary congestion.

Electrocardiogram (ECG) from a 47-year-old man with a long-standing history of uncontrolled hypertension. This image shows left atrial enlargement and left ventricular hypertrophy.

Electrocardiogram (ECG) from a 46-year-old man with long-standing hypertension. This ECG shows left atrial abnormality and left ventricular hypertrophy with strain.

Hypertrophied cardiac myocytes with enlarged "box car" nuclei.

Hypertension—or high blood pressure—can happen steadily over long time periods. The cause may not be clear (ie, primary hypertension) or hypertension may be caused by an underlying condition (ie, secondary hypertension).

Plasma aldosterone to renin activity ratio (ARR). If abnormal, refer for further evaluation such as saline infusion to determine if aldosterone levels can be suppressed, 24-hour urinary aldosterone level, and specific mineralocorticoid tests

Measurements outside of the clinical setting should be obtained for diagnostic confirmation before starting treatment.

No evidence was found for a single gold standard protocol for HBPM or ABPM. However, both may be used in conjunction with proper office measurement to make a diagnosis and guide management and treatment options.

Annually for adults age ≥40 and those at increased risk for high blood pressure including those who have high-normal blood pressure (130–139/85–89 mm Hg), are overweight or obese, or are African American.

Adults ages ≥18 to <40 years with normal blood pressure (≤130/85mm Hg) with no known risk factors should be screened every 3-5 years

Diagnosis based on 2 readings at 2 separate visits; For patients where diagnosis remains uncertain, home blood pressure monitoring (2-3 times a day for 7 days) or 24 hour ambulatory monitoring to confirm diagnosis

Periodic, preferably annually, at time of routine preventative care or health assessment;

Claude Kortas, MD, Med, FRCP(C) is a member of the following medical societies: American Society of Nephrology, College of Physicians and Surgeons of Ontario, Ontario Medical Association, and Royal College of Physicians and Surgeons of Canada

Mark A Silverberg, MD, MMB, FACEP Assistant Professor, Associate Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate Medical Center